Background: Benzodiazepines are often prescribed long-term inappropriately. We aimed to systematically review and meta-synthesise qualitative studies exploring clinicians' experiences and perceptions of benzodiazepine prescribing to build an explanatory model of processes underlying current prescribing practices.

Methods: We searched seven electronic databases for qualitative studies in Western primary care settings published in a European language between January 1990 and August 2011 analysing GP or practice nurse experiences of benzodiazepine prescribing. We assessed study quality using the Critical Appraisal Skills Programme Checklist. We analysed findings using thematic synthesis.

Results: We included eight studies from seven countries published between 1993 and 2010. Benzodiazepine prescribing decisions are complex, uncomfortable, and demanding, taken within the constraints of daily general practice. Different GPs varied in the extent to which they were willing to prescribe benzodiazepines, and individual GPs' approaches also varied. GPs were ambivalent in their attitude towards prescribing benzodiazepines and inconsistently applied management strategies for their use. This was due to the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs' attitudes to benzodiazepines, perceived lack of alternative treatment options, GPs' perception of patient expectations and the doctor-patient relationship. GPs faced different challenges in managing initiation, continuation and withdrawal of benzodiazepines.

Conclusion: We have developed a model which could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing through education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.